HAVERHILL, MA - Federal inspectors documented multiple violations at Oxford Rehabilitation & Health Care Center during a February 2025 inspection, including unsafe medication practices, failure to report abuse allegations, and equipment failures that affected all residents for several months.
Medication Administration Without Following Safety Protocols
Inspectors observed significant medication safety violations when a nurse administered medications to multiple residents without consulting the electronic health record system. On March 19, 2025, surveyors at two separate times documented the same nurse preparing and dispensing medications based solely on memory rather than following required verification procedures.
Between 7:16 and 7:24 A.M., the surveyor observed the nurse moving between two medication carts, neither of which had computer screens open to the medication administration record. The nurse prepared medications from various prescription cards, over-the-counter bottles, and removed narcotics from the drawer without referencing the narcotic book. When two residents approached the medication cart, the nurse handed each a cup of medications from the top drawer without checking the electronic record.
During a second observation at 7:40 A.M., inspectors again witnessed the nurse preparing medications from several different medication cards without reviewing physician orders. The computer screen on the medication cart displayed only a blank blue screen during medication preparation.
When questioned, the nurse acknowledged the violations, stating "she should not be preparing medications without reviewing the physician's orders" and admitted "she was not following the medication administration policy, and she was preparing and administering medications from her memory." The nurse added that "sometimes bad habits are hard to break."
Proper medication administration requires nurses to verify each medication against the physician's order, confirm the correct resident, dose, route, and timing. This "five rights" approach represents a fundamental safety standard designed to prevent medication errors that could result in adverse drug events, including incorrect dosing, drug interactions, or medications given to the wrong patient. When nurses bypass these verification steps, the risk of serious harm increases substantially.
The facility's medication error rate exceeded acceptable standards. When inspectors observed medication administration, they documented three errors out of 28 opportunities, resulting in a 10.71% error rate—more than double the 5% threshold permitted by federal regulations.
Critical Medication Errors Documented
Beyond the procedural violations, inspectors identified specific medication errors affecting individual residents. For one resident receiving Linzess for chronic constipation, the nurse administered the medication after breakfast when the physician's order specifically required administration 30 minutes before the first meal of the day. The medication bottle itself carried clear instructions: "take this medicine on an empty stomach, at least 30 minutes before the first meal of the day."
Linzess works by increasing intestinal fluid secretion and transit. Taking it with or after food significantly reduces its effectiveness and can alter its therapeutic benefits. The timing requirement exists not as a suggestion but as a critical component of the medication's proper use.
For another resident, inspectors observed two distinct medication errors during a single medication pass. The nurse administered two sprays of Azelastine nasal spray into each nostril when the physician's order specified one spray in both nostrils twice daily. Additionally, the resident received psyllium husk when the actual order was for FiberCon (calcium polycarbophil)—two different fiber medications with distinct mechanisms of action.
When questioned, the nurse said the resident received one capsule of psyllium husk "because that is what is provided by the facility." The Unit Manager confirmed that psyllium husk and calcium polycarbophil are not equivalent medications and stated "the facility should have the correct over the counter medications available for administration."
Infection Control Violations During Medication Administration
Compounding the medication safety concerns, inspectors observed the same nurse violating basic infection control practices by touching pills directly with ungloved hands during multiple medication passes. On two separate occasions, surveyors documented the nurse placing pills from medication cards and bottles directly into her bare hands before transferring them to medication cups.
This practice violates fundamental infection prevention principles. Medication should never be touched directly because hands carry microorganisms even after hand washing. During one observation, the nurse opened the medication cart with bare hands, then removed pills from three different medication cards and placed them directly into her contaminated hand before putting them in a medication cup. This cross-contamination could transmit bacteria or viruses between residents through shared medication packaging.
The nurse acknowledged the violation, stating "she was not supposed to touch the pills with her ungloved hands." The Director of Nursing confirmed that proper procedure prohibits pouring medications directly into hands.
Delayed Abuse Reporting
The facility failed to report allegations of abuse within required timeframes for a cognitively intact resident who submitted two grievance forms on February 24, 2025. The first grievance described an elevator incident on February 22 where another resident threatened to roll over the complainant's feet and called them derogatory names. The second grievance detailed an encounter with a security guard who threatened to have the resident "thrown out" of the facility.
The Social Worker received both grievances on February 24 but did not report them as suspected abuse. During the inspection, the Social Worker stated she "did not feel they warranted to be reported because it was a verbal altercation" and gave the forms to the Administrator expecting only customer service education for the security guard.
However, upon reviewing the grievances with inspectors, the Social Worker acknowledged that "threatening to roll over the resident's foot and threatening to have the Resident thrown out of the facility is concerning for verbal abuse." Facility policy requires reporting allegations of abuse to the State Agency within 24 hours if events do not involve physical abuse or serious bodily injury. The facility did not submit the report until February 25—24 hours after the allegation was made to the Social Worker.
Verbal abuse in long-term care settings can include threats, intimidation, and humiliation. For residents who depend on the facility for their care and housing, threats of eviction or physical harm can create significant psychological distress and fear for safety. Prompt reporting allows for timely investigation and intervention to protect residents from ongoing harm.
Failure to Implement Care Plans
Inspectors found the facility failed to implement care plans ensuring resident safety and dignity. For a resident with significant physical limitations from a stroke, staff repeatedly failed to place the call light within reach despite care plan requirements. On March 19, the resident was observed in bed with the call bell dangling behind the bed, inaccessible. The resident reported needing straws but being unable to call staff because "I could not reach the call bell."
The care plan specifically indicated "call light within reach," and the resident required total assistance from two staff members for mobility. Without access to the call system, the resident had no way to summon help in an emergency or for basic needs.
Similarly, for a resident with severe cognitive impairment and swallowing difficulties, staff failed to provide required feeding assistance during multiple meal observations. The resident's care plan indicated "max assist" for eating, yet staff allowed the resident to struggle independently, resulting in food falling into the lap and the resident resorting to eating with hands. During one observation, the resident's body leaned so far left that their hand was inches from the floor while attempting to eat, with no staff intervention.
Equipment and Respiratory Care Failures
The facility failed to ensure proper settings for essential medical equipment. For two residents with physician orders for specialty air mattresses at specific pressure settings, inspectors found the mattresses set incorrectly during multiple observations over several days. One resident's air mattress was ordered at 150 pounds but was consistently set at 325 pounds. Another resident's mattress was set at 80 pounds when ordered at 180 pounds.
Proper air mattress settings are critical for pressure injury prevention and healing. Settings based on patient weight ensure appropriate pressure redistribution. Incorrect settings can either provide insufficient pressure relief (increasing injury risk) or excessive inflation (reducing therapeutic benefit).
Inspectors also documented a resident receiving oxygen at incorrect flow rates over multiple days. The resident had physician orders for 4 liters per minute, but inspectors observed settings of 2.5 liters and 2 liters per minute during different checks. The resident had chronic respiratory failure requiring continuous supplemental oxygen. Insufficient oxygen flow can lead to hypoxemia (low blood oxygen levels), potentially causing organ damage, confusion, or respiratory distress.
Additional Issues Identified
The facility also faced citations for unsecured medications, with treatment rooms containing resident-specific creams and biologicals left unlocked and accessible to residents on multiple occasions. Medication carts were observed unlocked and unattended, violating basic medication security protocols.
Inspectors found the facility failed to maintain accurate medical records, specifically neurological assessment flowsheets following resident falls. Two separate fall incidents 23 days apart showed identical neurological assessment data, including vital signs, orientation levels, and nurse initials—suggesting documentation was copied rather than based on actual patient assessments.
Most significantly affecting quality of life, the facility's dishwasher had been non-functional since at least November 2024, forcing all residents to eat meals from Styrofoam containers with plastic utensils for approximately three months. During the resident group interview, 15 out of 15 residents confirmed they had been eating from disposable containers since Thanksgiving 2024. A new dishwasher had been delivered and sitting in the hallway since November 2024, but the facility had not completed installation despite having received installation quotes in late November.
The Director of Nursing, Administrator, and other leadership confirmed that medications should be administered according to physician orders, equipment should be maintained at proper settings, and professional standards must be followed for all aspects of care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oxford Rehabilitation & Health Care Center, The from 2025-02-27 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.